vision and hearing screening tools dissemination event for... · diagnostic audiometry re-tests:...

1

Vision and Hearing

Screening Tools

Dissemination Event

Agenda

8:30 – 8:45 a.m. Opening Program

8:45 – 9:00 a.m. Study background

9:00 – 9:15 a.m. Study procedures and methods

9:15 – 10:00 a.m. Demonstration

10:00 – 10:45 a.m. Presentation of findings

10:45 – 11:15 p.m. Presentation on the DepEd MFAT

11:15 – 11:35 p.m. Questions and Answers

11:35 – 12:00 p.m. Handover Ceremony & Closing

12:00 – 1:00 p.m. Lunch

11/12/2018 Vision and Hearing Screening Pilot Activity in the Philippines 2

Today’s Objectives

• Share approaches and lessons from the screening pilot

• Sensitize participants to important considerations in the

selection of screening tools and approaches based on

purpose, context, and resources


Using Mobile Technology

for Sensory Disability

Screening - Field

Experiences from the

Philippines

Kellie Betts

Carmen Strigel 11/12/2018 Vision and Hearing Screening Pilot Activity in the Philippines 4

What Is Screening?

• Process conducted by a non-medical staff or personnel to

determine whether a student might have a potential

disability

• Does not result in, or replace, a medical diagnosis by a

trained professional

• Screening is typically only for some aspects of a potential

disability

• Used to determine the need for referral and further

evaluation

• Screening approaches, by definition, are rapid and simplified

measures


Study Background and

Procedures


Study Origin

• Demonstrated commitment to inclusion by Department of

Education

• Commitment by USAID/Philippines to support the country’s

education development and inclusion agenda

• Emerging international evidence of a potentially higher than

15% disability prevalence rate

• Advancements in disability measurement and screening

approaches

• Emerging international evidence of practical approaches to

addressing drivers of low school enrollment and limited

implementation of inclusive education (RTI International, 2018)


Low school enrollment (and high dropout) of children with disabilities in low and middle-income countries

Socio-cultural barriers

Limitations in the operationalization of

national policies

Lack of materials & resources

Drivers of Low School Enrollment of Children with Disabilities

Lack of specialized materials to diversify instruction

Lack of individual assistive devices

Lack of appropriate financing of inclusive education policy in light of scarce resources

Lack of relevant data to inform policy and practice

Poor representation of disabled people organizations to include actual issues

Community and family hold negative attitudes to children with disabilities

Community and family do not know of value of education for disabled child

Principals, teachers, students hold negative attitude to children with disabilities…

Gaps in teacher development & support

Insufficient & inappropriate pre-service training…

Insufficient and inappropriate in-service training…

Insufficient instructional support and practical guidance…

Families with disability more likely to experience multi-dimensional poverty

Lower educational attainment is key contributor to poverty for persons with disability

Poverty

Lack of practical screening and assessment tools

…lead to low teacher self-efficacy in teaching children with disabilities in inclusive classrooms …

Poverty can be cause or product of disability

Factors established in literature

Absence of systematic early screening

Lack of accessible, affordable, & quality health care

Community and families do not have knowledge about disabilities, e.g., cause of disability

Large class sizes…

• Widely adopted, validated screening and measurement

tools for disabilities that can easily be adapted to local

context

• Research including learning outcomes of students with

different disabilities and severity levels

• Causal models that can underpin the plausibility of

interventions addressing barriers to inclusive education

• Cost-effectiveness research into different models of

inclusion (resource room, resource teacher, grade-based

phasing, etc.)


Gaps in the Current Evidence Base

Philippines Study Research Questions

1) Are the selected screening tools able to appropriately and

reliably detect children with vision and hearing difficulties

within the Filipino context?

–What are the necessary conditions to effectively

administer the selected tools?

2) Can the screening tools be effectively used by teachers in

the Philippines to screen and detect students with vision and

hearing difficulties?

–How much training is needed to ensure reliable screening

results?


Data Collection Instruments

Rapid user adoption test: Pre- and post-test that was administered individually to

screeners to gauge experience and skill levels prior to training (use of electronics, use of

the specific software) and then compared to screeners’ abilities at the end of training

hearScreen: Smartphone-based hearing screening test developed by HearX, South Africa

Peek Acuity: Smartphone-based vision screening test developed by Peekvision, UK

Student background interview: Brief interview conducted with children; included the

Washington Group Short Set of Disability Questions

Diagnostic audiometry re-tests: Hearing tests conducted in medical facility as re-tests

for select students who tested positive at schools when using hearScreen

Principal interview: A brief interview to answer background questions about the school,

disability among students in the school, and the school’s inclusive education program.

Screener performance instrument: Collected data on the accuracy of screeners in

administering the vision and hearing screening

Screener exit interviews: Interview with screeners at the end of the data collection

gathering feedback on the tools, training, and data collection process


School and Student Sample

• 8 schools selected, conveniently located in Region IV and

National Capital Region

–All medium- to large-size schools; located around

cities/major roads; constructed in/around the school

• 1,218 children (50% boys and 50% girls)

–Grade 1: 190 students




Screening Spaces Used in Schools

45%

38%

8%

6%

2%

2%

0% 10% 20% 30% 40% 50%

Inside an empty classroom

Inside a classroom with other

students/teachers present

Inside a small, private office

Outside in a public area (others are

present)

Outside in a private area

Other


Pilot Screeners

• 18 screeners trained

– 8 teachers

– 4 medical officers (under the School Health Division)

– 6 data collectors (principals and school supervisors)

Screener type Average

age

Average years of

experience (range)

Teacher 39 11 years (2–20 years)

Medical Officer 40 10 years (1–11 years)

Data Collector 50 21 years (9–28 years)


Peek Acuity

• Vision acuity screening

• Screener-administered

• Already piloted in Ethiopia and several

other countries in Africa and Asia

• Clinically validated (De Venecia et al., 2018)

• Proprietary tool

Vision and Hearing Screening Pilot Activity in the Philippines 15

hearScreen

• Pure tone audiometric screening


• Default protocol: sounds at 3 frequencies both right and left ear

• Clinically validated (Faheema et al., 2016)


• Headset calibration to specific hardware


DEMONSTRATION

17Vision and Hearing Screening Pilot Activity in the Philippines

Vision Screening Pilot Findings


Peek Acuity

• Vision acuity screening


• Already piloted in Ethiopia and several

other countries in Africa and Asia

• Clinically validated (De Venecia et al., 2018)



Percent of Screened Children with Potential Vision

Impairment by Severity Level (n=1,218)

93.68%

2.38%3.61%

0.25%

Normal Mild Impairment

Moderate Impairment Severe Impairment

20Vision and Hearing Screening Pilot Activity in the Philippines

Vision Screening Referrals by Region and Gender

• Number of referrals significantly higher in NCR than Region IV-A

– Aligns with DepEd Consolidated SPED Data 2016–2017 that

shows NCR has the highest level of diagnosed and undiagnosed

vision impairments among elementary-aged students

• Slightly higher number of referrals for girls

NCR

(n=551)

REGION IV-

A (n=667)

Male

(n=611)

Female

(N= 606)

Normal 481 660 580 561

Mild

Impairment 27 2 8 21

Moderate

Impairment 39 5 23 21

Severe

Impairment 3 0 0 3


Hearing Screening Pilot Findings


hearScreen

• Pure tone audiometric screening


• Default protocol: sounds at 3 frequencies both right and left ear

• Clinically validated (Faheema et al., 2016)


• Headset calibration to specific hardware


hearScreen Tool Adjustments during Pilot

• Days 1–3: Referral rates using Standard Protocol extremely high (88% and 95%

of screened students)

– Left and right ear tests at 25 dB at 1kHz, 2kHz, and 4kHz

– Referrals at 1 or more failed frequencies

• On Day 4 and on Day 5: Small decrease in referral rate using Severity Protocol

– Left and right ears tested starting at 25 dB at all 3 frequencies; if no

response at 25 dB, beep is presented at increasingly higher frequencies

until patient responses

– Referrals at 1 or more failed frequencies

• Days 6–8: Significant increase in pass rate using a modified Severity Protocol

– Left and right ears tested starting at 30 dB at all 3 frequencies

– Refers at 2 or more failed frequencies

dB: degree of loudness

Hz: a unit of alternating current


Hearing Screening Results by Day

NCR Region IV

Day 1

(n=66)

Day 2

(n=164)

Day 3

(n=144)

Day 4

(n=205)

Day 5

(n=112)

Day 6

(n=178)

Day 7

(n=201)

Day 8

(n=190)

Referred 89% 96% 90% 76% 78% 7% 7% 2%

Passed 11% 4% 10% 24% 22% 93% 93% 98%

Protocol

Used

Standard

Protocol

Standard

Protocol

Standard

Protocol

Standard

Severity

Protocol

25 dB

Standard

Severity

Protocol

25 dB

Modified

Severity

Protocol

30 dB

& 2 failed

frequencies

Modified

Severity

Protocol

30 dB & 2

failed

frequencies

Modified

Severity

Protocol 30

dB & 2

failed

frequencies

11/12/2018 26Vision and Hearing Screening Pilot Activity in the Philippines

Hearing Referrals by Severity Level

79%

90% 91%

16%

5% 6%4% 3% 2%1% 3% 1%0%

20%

40%

60%

80%

100%

Day 6 Day 7 Day 8

% o

f sc

reened s

tudents

None Mild Moderate Moderate Severe


Considerations and Recommendations:

Using Schools Settings for Screenings


Considerations: Using Schools for Screenings

• Schools can have higher than desired ambient noise levels from teachers, students,

parents, class breaks/shift change, etc.

• hearScreen tool constantly monitors background noise during screening process

– Automatically rescreens failed frequencies if ambient noise levels were above

permissible levels

• Permissible ambient noise levels are 49, 57, and 61 dB for 1, 2, and 4 kHz,

respectively

0%

20%

40%

60%

80%

100%

Visual distractions

present

Noise

distractions

present

Adequate lighting

available

Screener-Reported Testing Conditions

Yes No


Chapter VI: School Sanitation and Health Services

The Code on Sanitation in the Philippines, Department of Health


Ambient Noise Levels in Pilot Schools

0

10

20

30

40

50

60

70

80

90

100

20.0

25.0

30.0

35.0

40.0

45.0

50.0

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8

Refe

rral

rat

e o

f st

udents

(%

)

Am

bie

nt

nois

e leve

l in

dB

s

1 kHz 2 kHz 4 kHz Fail Rate


49 dB- 1000 Hz

57 dB- 2000 Hz

61 dB- 4000 Hz

Recommendations: Using Schools for Screenings

• Be aware that school settings do present challenges, especially for

electronic hearing screening

– Consider larger implications related noise levels in schools

• Screening space set-up is critical to performance of tools

– 1 or 2 screeners in a room

– Be aware of school break times/shift changes

– Small offices or empty classrooms

• Test/adjust tool settings

• Closely monitor referral rates

• Consider screening outside of the normal school day (e.g., at the end

of the day, Saturday, or before the school year starts)



Screener Type


Considerations: Screener Type

• Using teachers as screeners helps them better understand which students have a potential vision or hearing impairment

– Can adjust their teaching or classroom practices to provide necessary assistance to students most in need

• Medical officers tend to have more experience with screening and referral processes; might be better at communicating results to parents

• Data collectors are especially useful in the parent-notification process


Screener Performance by Type

86%

88%

90%

92%

94%

96%

98%

100%

Vision tasks (18) Hearing tasks (11)

% o

f perf

orm

ance

obse

rvat

ions

Percent of screeners’ performance observations

without errors by screener type

Data Collector Medical Officer Teacher

Source: Screener Performance Observation


Understanding How to Use Screening Results

QUESTION: How do you plan on using the results of today’s screenings?

• Teachers: Tend to focus on individual child/family support (e.g.,

notifying parents of referral and allow family to follow up); few aware of

action items for classroom/teaching methodologies that could provide

additional support to children with a potential hearing or vision

impairment

• Medical Officers: Want to use the data to dig deeper to explore

issues behind the impairment; interested in being involved in screenings

to work with teachers and parents to understand results

• Data Collectors:Want to focus on communicating to and advising

parents to have a second opinion to justify the results; look for

sponsors/funding to help parents fund additional assistance/screenings


Support Needed to Use Screening Results

QUESTION: What other types of support would you need in order to use

today’s results or to continue to support the identified children in the future?

• Teachers: Most teachers were unsure of what other types of support

they would need to effectively use the results or continue to support

identified children

• Medical Officers: Want to learn how to use the data to get support

(financial and other) from other agencies; how to educate and talk to

parents of the identified students

• Data Collectors: Budget for parents to get second opinions


Recommendations: Screener Type

• Teachers are able to pick up and use tools with relative ease

– Teachers’ gains (33%) are similar to those of Medical Officers

(35%) and Data Collectors (36%) in Rapid User Adoption Test

• Teachers tend to have better rapport with students during screening

process

• Teachers need additional support (training/intervention) to understand

how to use screening results at classroom level

• Continue to involve medical officers in screening process

– Medical officers might have better understanding of referral

process and knowledge of local medical facilities for follow-up

testing



Training Duration and Design


Considerations: Training Duration And Design

Tools were user-friendly and easy to administer; all screeners were able

to pick up tools with relatively small amount of training time

42%50%

42%

75%

85%78%

33% 35% 36%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Teachers Medical Officers Data Collectors

Rapid User Adoption Results

Average Pre Score Average Post Score Average Gain


Recommendations: Training Duration and Design

• Extend training by one day to allow for more practice, for a

total of 24 hours of training

• Provide extra practice in school setting

–Allows for better understanding of working with

children and challenges with setting up testing space

• Spend more time in training to ensure screeners

understand findings/severity levels to better communicate

them to parents



Screening Age


Considerations: Screening Age

• Noticeable differences in children’s

(grade 1 vs. grade 3) ability to understand

directions and concentrate during

screening process

• Some hearing impairments such as middle

ear pathologic disorders are known to be

more common in younger children

(age 5), and referrals tend to reduce for

children ages 6 and 7 (Swanepoel,

Eikelboom, and Margolis, 2014)

1st

grade

(n=190)

2nd

grade

(n=814)

3rd

grade

(n=214)

Referred 82% 37% 63%

Pass 18% 63% 37%


Recommendations: Screening Age

• Early screening and detection remains important

• Recognize that some conditions such as ear infections that

may affect hearing can be temporary and are often more

common with younger aged children

• Use clear instructions when working with younger

students; understand it may take longer to screen younger

children

• Use conditioning to help ensure younger students

understand screening process



Parent Notification and Referral Process


Considerations: Parent Notification and Referral

Process

• Notification and parent

engagement is critical to

screening process

• Many parents didn’t provide

consent for students to

participate

• Parents don’t always understand

what referrals/screening results

mean

• Parents don’t always want to

seek further testing/know more

about the potential issues


Recommendations: Parent Notification and Referral

Process

• Need careful, context-specific consideration of socio-cultural aspects

• Explore other methods to communicate to parents about screening tools and procedures

– Show videos of screening process

– Discuss the screenings at PTA meetings or other scheduled meetings with parents

– Communicate verbally rather than through letters; allow parents to ask questions

• Prepare screeners with better understanding of the results/severity levels to improve ability to communicate findings to parents

– Sensitize/support parents with screening results

– Be able to suggest clear next steps (in and out of schools)



Tool Selection


Considerations: Tool Selection

• Screening tool must be carefully selected, taking into

account:

– Type of disability to screen for

– Purpose of the screening activity (and related to use of

the resulting data)

–Age of the child

– Resources available for screening and screening follow-

up

– Screening context


Sample Students Self-Report Using Washington

Group Short Set Questions

Self-reported

difficulty

hearing

Self-reported

difficulty

seeing

Self-reported

difficulty

walking/clim

bing

Self-reported

difficulty

concentratin

g

Self-reported

difficulty

with self care

Cannot do at all 1% 0% 0% 1% 1%

Yes, a lot of difficulty 1% 2% 1% 0% 1%

Yes, some difficulty 10% 10% 7% 18% 7%

No, no difficulty 88% 88% 91% 80% 91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%%

of sc

reened s

tudents


Small Overlap Between Washington Group Short

Set and Electronic Screening Results

• 27% of the students who did not pass the Peek Acuity screening indicated

difficulty seeing

• 11% of students indicated difficulty seeing but passed Peek Acuity screening

• 6% of students who indicated difficulty hearing also did not pass the

hearScreen test

• 6% of students who indicated difficulty hearing passed the hearScreen test


Hearing Screening Test Retest Results

• 162 students were retested after not

passing hearing screening

• Retesting students on the spot reduced

referral rates by almost 30%

First Test

Result

Last Test

Result

# of

students

(n=162) Percent

Fail Fail 107 66%

Fail Pass 44 27%


Recommendations: Tool Selection

• Carefully consider context and purpose prior to selecting

screening tools.

• Screening efforts must invest in careful initial field tests to

establish locally appropriate logistics guidance for screeners

on where and how to set up adequate screening spaces.

• Comprehensive testing of electronic hearing screening

tools is needed to identify the most viable protocols for

the context in advance of full rollout.

• Screeners should retest students to ensure screening gives

accurate results.


References

De Venecia, B., Bradfield, Y., Møller Trane, R., Bareiro, A., & Scalamogna, M. (2018). Validation

of Peek Acuity application in pediatric screening programs in Paraguay. International Journal of

Ophthalmology, 11(8), 1384–1389. doi:10.18240/ijo.2018.08.21

Swanepoel D., Eikelboom R., & Margolis, R. (2014). Tympanometry Screening Criteria in

Children Ages 5–7. Journal of the American Academy of Audiology, 25(10), 927-936.

doi:10.3766/jaaa.25.10.2.


Kellie Betts, RTI International

[email protected]

Carmen Strigel, RTI International

[email protected]

Monica Ang-Tan, USAID/Philippines

[email protected]

Bureau of Learning Delivery- Student Inclusion Division

[email protected]


Contact Information

mailto:[email protected]




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